Initial Insights into ICD-11 Complex PTSD and Emotional Distress in Emerging Adults in India: Prevalence,Predictors,and Psychosocial Correlates

Abstract

Background:

The increasing emotional distress among emerging adults highlights the importance of examining trauma-related factors, particularly complex trauma. This study investigates post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder (C-PTSD), and emotional distress, emphasizing the predictive role of disturbances in self-organization (DSO) as defined by the International Classification of Diseases (11th revision) (ICD-11).

Methods:

A cross-sectional study was conducted among 538 college-going emerging adults (aged 15–29 years). The study received ethical clearance from the institute and informed consent from the participants, who completed validated measures: the International Trauma Questionnaire and Depression, Anxiety, and Stress Scale-21. Quantitative data were analyzed using descriptive statistics, Mann-Whitney/Kruskal-Wallis tests, Pearson’s correlation, and multiple linear regression. Thematic analysis was used to explore self-reported traumatic experiences.

Results:

Prevalence rates were 15.2% for C-PTSD, 20.8% for PTSD, 53.9% for depression, 66.5% for anxiety, and 36.2% for stress. DSO showed the strongest associations with all three domains of emotional distress. Thematic analysis revealed multidimensional trauma themes, including career anxiety, relational issues, abuse, loss, and social exclusion. Gender and psychiatric history significantly moderated distress levels, while rural-urban background showed no difference.

Conclusions:

Among the variables, DSO demonstrated the strongest and most consistent associations with depression, anxiety, and stress, pointing to its close link with complex trauma responses. Results highlight the need for trauma-informed screening and interventions in Indian academic settings and support ICD-11’s distinction between PTSD and C-PTSD. A tiered intervention model is recommended for early detection and tailored care.

Keywords

C-PTSD emerging adulthood emotional distress PTSD trauma-informed intervention

Key Messages:

Question: What is the prevalence and psychosocial impact of ICD-11 C-PTSD and DSO among emerging adults within the Indian context?

Findings: C-PTSD was identified in 15.2% and PTSD in 20.8% of participants. DSO showed the strongest associations with depression, anxiety, and stress, underscoring its central role in complex trauma responses.

Meaning: Trauma-informed and tiered mental health interventions are needed in Indian academic settings to address complex trauma and emotional distress among emerging adults.

Globally, emotional distress among emerging adults is alarmingly high, with the pooled prevalence of 37.1% for depression, 41.4% for anxiety, and 44.9% for stress.¹ Indian estimates are even higher, 48%, 54%, and 50%, respectively.² These rates underscore the need to investigate associated factors for improved prevention and care. Trauma is a key transdiagnostic risk factor highly associated with mood and anxiety disorders, with enduring effects on brain functions and related academic and social difficulties.^3–6

International Classification of Diseases, 11th Revision (ICD-11) introduced complex-post-traumatic stress disorder (C-PTSD) as distinct from post-traumatic stress disorder (PTSD), adding disturbances in self-organization (DSO), which includes emotional dysregulation, negative self-concept, and relationship difficulties, resulting from prolonged and repetitive exposure to traumatic events from which escape is difficult.⁷ It replaces earlier diagnoses like “disorders of extreme stress not otherwise specified” and “enduring personality change after catastrophic experience”. It differs from borderline personality disorder, which centers on affective instability and fear of abandonment.^8,9

The prevalence of C-PTSD and PTSD is reported to be 7.7% and 5% in Ireland and 3.8% and 3.4% in the US.^10,11 Indian data are scarce, with the National Mental Health Survey (2015–2016) reporting PTSD at 0.2%, which is lower than the Western average.¹² Although a meta-analysis among Asian adolescents, including Indians, estimated PTSD prevalence at 14.4%.¹³ Further, Indian studies report 4.6% of C-PTSD prevalence in adolescents who were exposed to bullying, violence, and socio-cultural adversities.¹⁴ C-PTSD is also linked to greater cognitive impairments and mood/anxiety comorbidity than PTSD.^¹5,¹6 Data on C-PTSD and PTSD remain understudied in Indian emerging adult populations. Moreover, this developmental phase is marked by identity exploration, instability, and increased independence, emotional vulnerability, which makes one more susceptible to repeated trauma exposure, warranting focused attention.^17,18

Novelty

This is an initial study in the Indian context to assess the prevalence of Complex PTSD along with PTSD using ICD-11 criteria among emerging adults, alongside their association with emotional distress symptoms. Focusing on the predictive role of DSO and PTSD domains in depression, anxiety, and stress, the study offers novel insights into trauma-related emotional health vulnerabilities in a culturally specific and under-researched population.

Objectives

To assess the prevalence of emotional distress and C-PTSD and PTSD among emerging adult students in India.

To examine the relationship between C-PTSD and PTSD, and emotional distress.

To identify the core components of DSO and PTSD that are significantly associated with emotional distress.

Methods

Participants

This study sample consisted of 538 emerging adults aged between 15 and 29 years (M = 20.87, SD = 2.27). The sample included 66% females, 32.7% males, and 1.3% non-binary. The maximum participants were from nuclear families (82.2%), while 17.8 % were from joint families. In terms of residential background, 63.3% of them were from urban areas, 23.5% from rural areas, and 13.2% from semi-urban areas. For the history of psychiatric illness, 18.4% reported a history and treatment, 70.6% denied, and 11% were uncertain, having never consulted. Participants who reported having a positive history and those who were uncertain about it had significantly higher levels of psychological distress across variables compared to those with a negative history. Significant difference was found for depression (χ² = 111.69, df = 2, p < .001), anxiety (χ² = 101.79, df = 2, p < .001), stress (χ² = 89.68, df = 2, p < .001), PTSD (χ² = 88.64, df = 2, p < .001), and DSO (χ² = 116.95, df = 2, p < .001).

Procedure

A cross-sectional research design was utilized, complemented by qualitative thematic analysis to explore participants’ subjective accounts of traumatic events experienced throughout their lifetime. The study was approved by the institutional ethical committee of a medical university in February 2023. The data was collected between April 2023 and June 2023. Formal approval to include students from two colleges was obtained before recruiting participants for the study. It was ensured that participants were enrolled in English-medium instruction, as all study measures were administered in English. Before distributing the survey questionnaires to the participants, they were formally informed about the study’s objectives and implications in chunks to the groups in the classroom set-ups. They provided informed consent, which included information on their voluntary participation, right to withdraw from the study at any point during the study participation, assurance of confidentiality, and privacy of the data. To ensure participant privacy, only the initials of their name were collected. Participants were informed that there would be no monetary compensation or tangible benefits for participating in the study. However, they were also informed about the student support center (the center has a team of psychiatrists, clinical psychologists, and psychiatric social workers) in the reputed university, with the contact details in case they felt the need to seek professional help during or after the study procedure. The data collection process involved distributing the online survey on social media platforms. The study adhered to the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines to ensure transparency in reporting online survey methodology (see supplementary material-CHERRIS Checklist). The survey included informed consent, demographic information, history of psychiatric illness, measures of psychological distress (depression, anxiety, and stress), PTST, and C-PTSD. In total, over eight hundred participants were given the link to the online survey questionnaire, and a total of 554 responses were received. Sixteen of them were excluded. Responses were excluded due to incompleteness (10 cases) and failure to meet the inclusion criteria (6 cases). Since the excluded participants did not differ systematically in their demographic profiles from the retained sample, the likelihood of selection bias is minimal. This resulted in a final sample of 538 participants, exceeding the estimated requirement of 500 derived through G*Power.^19–21 The G*Power calculation was applied to regression prediction models, which were the primary focus of this study, while prevalence estimates were reported descriptively. After data collection, investigators checked item-wise data on all the measures to check the suitability of the data in Excel sheets. After coding, the data was secured in a password-protected computer.

Measures

Demographic Datasheet

This involves demographic information, such as age, sex, family type, and residential background. In addition, this also includes the clinical information on the presence of psychiatric history and treatment.

Depression Anxiety Stress Scale-21

Depression, anxiety, and stress-21 (DASS-21) is a brief self-report measure derived from the full-length 42-item scale by Lovibond and Lovibond (1995) to assess the symptoms of depression, anxiety, and stress. Each subscale has seven items rated on a 4-point Likert scale (0–3). The obtained scores are doubled to align with the more extended version. It has demonstrated high internal consistency (α = 0.91 for depression, 0.80 for anxiety, 0.84 for stress) and a stable three-factor structure confirmed across multiple studies. This measure is available for use in the public domain.^22,23

International Trauma Questionnaire

The International Trauma Questionnaire (ITQ) is a self-report measure to assess PTSD and C-PTSD and was developed based on ICD-11 criteria for both disorders. It has 12 core symptom items, which incorporate the six domains (three for PTSD and three for DSO). In addition, it has six items for assessing functional impairment. Items are rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). People with a score of 2 or more per individual symptom items are considered positive for the said criteria of C-PTSD and PTSD. ITQ has shown adequate psychometric properties, including high international consistency (α ≥ 0.77), and supports a good factor structure across the samples. This measure is freely available in the public domain for use in research and clinical practice.²⁴

Data Analysis

The study was analyzed using IBM SPSS 20.0.²⁵ Descriptive statistics, that is, mean, standard deviation, frequency, and percentage, were used to describe the findings. Non-parametric tests, that is, Kruskal-Wallis and Mann-Whitney tests, were used to examine differences in PTSD/DSO and psychological/emotional distress variables across demographics such as age, sex, residence, family types, and clinical variables such as history of psychiatric illness. Cronbach’s Alpha was used to check the reliability of the tools for the current study. Pearson’s correlation was used to see the relationship between PTSD/DSO and emotional distress variables. After analyzing and evaluating the strength of correlations across the derived correlation coefficients, multiple linear regression using the stepwise method was used to explore the key contributors to depression, anxiety, and stress from the DSO and PTSD symptoms domains. A stepwise method was preferred to find the most to least predictive models. Assumptions for multiple linear regression were met, including linearity, homoscedasticity, and independence of errors (Durbin-Watson: 1.86–2.01). Residuals were within acceptable standardized limits (±3.29), with slightly extended ranges for anxiety and depression. Cook’s Distance and leverage values indicated no influential outliers, supporting model stability and reliability. Variance Inflation Factor values for all contributors were below 2, indicating no serious issues of multicollinearity between PTSD and DSO variables.²⁶ Thematic analysis was conducted on participants’ accounts of traumatic events, involving open coding, categorization, and iterative refinement through constant comparison and peer debriefing to ensure credibility and trustworthiness.

Results

Table 1 presents the prevalence of trauma-related symptoms and emotional distress among the sample of 538 emerging adults. Of the total participants, 15.2% met the criteria for C-PTSD, while 20.8% fulfilled the diagnostic criteria for PTSD based on the ICD-11 framework. Emotional distress, assessed using the DASS-21, revealed that 53.9% of participants reported symptoms of depression, 66.5% reported symptoms of anxiety, and 36.2% reported symptoms of stress. The severity classifications for each emotional distress domain, ranging from mild to extremely severe, are detailed in the table. These findings underscore the substantial psychological burden, particularly of anxiety, among emerging adults in the current sample.

Table 1.

Descriptive Statistics of the Sample (N = 538).

Variable	Category/Scale	n/Mean	%/SD
DASS-21 Severity Levels
Depression	Normal	248	46.1%
	Mild	75	13.9%
	Moderate	97	18.0%
	Severe	46	8.6%
	Extremely severe	72	13.4%
Anxiety	Normal	180	33.5%
	Mild	38	7.1%
	Moderate	142	26.4%
	Severe	54	10%
	Extremely severe	23	23%
Stress	Normal	343	63.8%
	Mild	68	12.6%
	Moderate	56	10.4%
	Severe	44	8.2%
	Extremely severe	27	5.0%
PTSD criteria	Positive	112	20.8%
PTSD criteria	Negative	426	79.2%
C-ptsd criteria	Positive	82	15.2%
C-ptsd criteria	Negative	456	84.8%
PTSD subscale scores	Re-experiencing	4.82	2.73
	Avoidance	2.74	2.08
	Threat	2.81	2.27
	PTSD functional impairment	3.53	3.59
	PTSD total	11.41	7.74
DSO subscale scores	Affective dysregulation	3.10	2.32
	Negative self-concept	2.58	2.74
	Disturbances in relationships	3.19	2.45
	DSO functional impairment	3.98	3.64
	DSO total	12.85	9.84
DASS-21 mean score	Depression	12.92	10.670
	Anxiety	12.71	9.785
	Stress	13.46	9.590

SD = Standard deviation; DASS-21 = Depression anxiety stress scales-21 items; PTSD = Post-traumatic stress disorder; C-PTSD = Complex-post-traumatic stress disorder; DSO = Disturbances in self-organization.

A substantial proportion of the sample (66%) consisted of female participants, who scored significantly higher than their male counterparts on all study variables. Kruskal-Wallis tests further demonstrated that the participants who chose not to disclose sex reported the highest levels of emotional distress across all the indicators, with mean ranks of 428.86 for depression, 477.21 for anxiety, 410.57 for stress, 444.93 for PTSD, and 458.93 for DSO. Female participants were found to have significantly more psychological distress compared to males. The mean ranks in terms of females vs. males are as follows: for depression (282.95 vs. 238.05), anxiety (284.11 vs. 231.77), stress (290.83 vs. 220.87), PTSD (280.95 vs. 240.01), and DSO (283.29 vs. 234.16). Statistical significance of differences across sex groups are as follows: for depression (χ² = 16.93, df = 2, p < .001), anxiety (χ² = 26.14, df = 2, p < .001), stress (χ² = 29.84, df = 2, p < .001), PTSD (χ² = 17.02, df = 2, p < .001), and DSO (χ² = 22.32, df = 2, p < .001).

In terms of their residence type, that is, rural, urban, and semi-urban, we did not find any significant difference for depression (χ² = 1.97, df = 2, p = .37), anxiety (χ² = 1.06, df = 2, p = .58), stress (χ² = 4.90, df = 2, p = .08), PTSD (χ² = 1.18, df = 2, p = .55), and DSO (χ² = 3.54, df = 2, p = .17). Mann-Whitney U tests revealed that nuclear family participants had significantly higher depression scores as compared to joint family (275.92 vs. 239.96; U = 18380.50, z = 2.06, p = .03). However, for family types, there was no significant difference observed in stress (U = 19027.50, p = .11), anxiety (U = 19851.50, p = .32), PTSD (U = 20797.00, p = .76), and DSO (U = 19150.00, p = .13).

Participants who reported a positive history of psychiatric illness and treatment, as well as those who suspected they had a psychiatric condition but had never received a formal diagnosis or treatment, exhibited significantly higher levels of psychological distress and trauma-related symptoms across all measured domains. Kruskal-Wallis tests revealed statistically significant group differences for depression (χ² = 111.69, df = 2, p < .001), anxiety (χ² = 101.79, df = 2, p < .001), stress (χ² = 89.68, df = 2, p < .001), PTSD (χ² = 88.64, df = 2, p < .001), and DSO (χ² = 116.95, df = 2, p < .001).

Mean ranks indicated that individuals with a confirmed psychiatric history had elevated scores on all outcome variables: depression (373.42), anxiety (370.59), stress (360.90), PTSD (353.93), and DSO (370.00). Participants who reported suspected psychiatric conditions (but had not sought clinical confirmation) showed even higher mean ranks: depression (388.03), anxiety (379.77), stress (378.30), PTSD (387.08), and DSO (399.84). In contrast, participants who denied any history of psychiatric illness had markedly lower mean ranks across all variables: depression (224.02), anxiety (226.04), stress (228.80), PTSD (229.25), and DSO (223.08). These results underscore the heightened vulnerability and psychological burden in individuals with actual or perceived psychiatric morbidity.

A small subgroup of participants aged 15–17 years (n = 8), outside the emerging adulthood range, was compared with the 18–29 group (n = 530) to assess developmental confounds. No significant differences were found for stress (U = 1772.00, p = .42), anxiety (U = 1300.00, p = .060), depression (U = 1961.00, p = .71), PTSD (U = 1542.00, p = .18), or C-PTSD (U = 2079.00, p = .92), indicating that inclusion of this subgroup did not bias the findings.

The ITQ has not been previously validated in the Indian population. To assess whether the ITQ and the DASS-21 (validated in the Indian population) reliably measured the intended constructs in the emerging adult sample of the present study, internal consistency was evaluated using Cronbach’s alpha. The ITQ demonstrated good to excellent internal consistency, with α = 0.94 for the full scale, α = 0.86 for PTSD, and α = 0.93 for DSO. Within the PTSD subscales, reliability was lower for re-experiencing (α = 0.58) and avoidance (α = 0.66), and acceptable for sense of threat (α = 0.68), suggesting moderate consistency in these domains. The DSO subscales showed stronger reliability, with affective dysregulation (α = 0.78) and disturbance in relationships (α = 0.75) falling in the acceptable-to-good range, and negative self-concept (α = 0.92) demonstrating excellent consistency. For the DASS-21 subscales, Cronbach’s alpha was 0.89 for depression, 0.86 for anxiety, and 0.86 for stress. These values reflect robust psychometric properties in the study sample.^{11,22–24,27}

In response to the ITQ item, Please identify the experience that troubles you most and answer the questions in relation to this experience, the participants reported different events and situations as traumatic. Using thematic analysis of the responses, several major themes emerged, representing the broad categories, that is, future and career anxiety, family conflict, death or loss of loved ones, abuse or assault, physical illness or accidents, bullying and body shaming, break-up or relationship issues, social isolation and loneliness, and social anxiety.

From the above major themes, salient sub-themes were identified, reflecting the subtle nature of their traumatic experiences. These include fear of the future, academic failure, loss due to suicide or sudden accidents, emotional abuse and childhood maltreatment, sexual assault and boundary violations, loss of parents or primary caregivers, chronic illness and disability, social rejection, peer pressure, and marginalization.

Table 2 presents the Pearson correlation coefficients between DSO/PTSD domains and depression, anxiety, and stress. All the domains of both trauma-related variables (DSO and PTSD) showed a significant correlation with DASS-21 subscales measuring depression, anxiety, and stress at the 0.001 level. Among PTSD components, threat appraisal and functional impairment demonstrated the strongest association with all three domains of DASS-21, depression (r = 0.53, p < .001 and r = 0.69, p < .001), anxiety (r = 0.54, p < .001 and r = 0.59, p < .001), and stress (r = 0.55, p < .001 and r = 0.59, p < .001). In DSO domains, negative self-concept and DSO total score showed the highest correlations, particularly with depression (r = 0.82, p < .001). These significant correlations between trauma-related variables and emotional distress provided a strong empirical basis for including both the total and domain-specific scores of DSO and PTSD as contributors in the multiple linear regression analyses of emotional distress outcomes.

Table 2.

Pearson’s Correlations of DASS-21 Scores with PTSD and DSO Domain Scores (N = 538).

Variables	Depression	Anxiety	Stress
Re-experiencing	0.30**	0.28**	0.32**
Avoidance	0.48**	0.47**	0.48**
Threat appraisal	0.53**	0.54**	0.55**
PTSD functional impairment	0.69**	0.59**	0.59**
PTSD total score	0.71**	0.65**	0.68**
Affective dysregulation	0.66**	0.60**	0.65**
Negative self-concept	0.80**	0.59**	0.65**
Disturbance in relationships	0.71**	0.62**	0.68**
DSO functional impairment	0.72**	0.61**	0.67**
DSO total score	0.82**	0.69**	0.75**

DASS-21 = Depression anxiety stress scales-21 items; PTSD = Post-traumatic stress disorder; DSO = Disturbances in self-organization; ** = Significant at 0.001 level.

Before conducting regression analyses using multiple linear regression, all key assumptions for multiple linear regression were assessed and were found in acceptable ranges (see data analysis). The findings from Tables 3 and 4 are presented below, organized under the respective subheadings: prediction of depression, anxiety, and stress.

Table 3.

Summary of Regression Model Fit Indices for Predicting DASS-21 Subscale Scores.

Outcome	Model No.	Predictors	R	R²	Adj. R²	Std. Error	F Change	df1	df2	Sig. F Change	Cohen’s f ^²
Depression	1	DSO	0.82	0.68	0.68	5.98	1171.95	1	536	0.001	2.12
	2	DSO, NSC	0.84	0.71	0.70	5.75	44.09	1	535	0.001	2.45
	3	DSO, NSC, PTSD	0.84	0.71	0.71	5.70	10.85	1	534	0.001	2.45
Anxiety	1	DSO	0.69	0.48	0.47	7.06	494.04	1	536	0.001	0.92
	2	DSO, PTSD	0.70	0.49	0.49	6.93	20.82	1	535	0.001	0.96
	3	DSO, PTSD, DSOFI	0.71	0.50	0.50	6.90	5.59	1	534	0.018	1
Stress	1	DSO	0.75	0.57	0.57	6.26	722.21	1	536	0.001	1.32
Stress	2	DSO, Threat	0.76	0.58	0.58	6.20	12.15	1	535	0.001	1.38

DSO = Disturbances in self-organization; PTSD = Post-traumatic stress disorder; NSE = Negative self-concept; DSOFI = Disturbances in self-organization functional impairment; Threat = Threat appraisal.

Table 4.

Standardized Beta Coefficients for Trauma-related Predictors of Depression, Anxiety, and Stress.

Outcome	Model No.	Predictors	B	Std. Error	β	t	Sig.	sr²
Depression	1	DSO	0.89	0.02	0.82	34.23	0.001	0.68
	2	DSO	0.58	0.05	0.54	11.07	0.001	0.18
	2	NSC	1.26	0.19	0.32	6.64	0.001	0.07
	3	DSO	0.43	0.07	0.39	6.09	0.001	0.06
		NSC	1.37	0.19	0.35	7.18	0.001	0.08
		PTSD	0.19	0.05	0.14	3.29	0.001	0.01
Anxiety	1	DSO	0.68	0.03	0.69	22.22	0.001	0.47
	2	DSO	0.47	0.05	0.47	8.56	0.001	0.12
	2	PTSD	0.32	0.07	0.25	4.56	0.001	0.03
	3	DSO	0.61	0.08	0.61	7.68	0.001	0.09
		PTSD	0.36	0.07	0.28	5.00	0.001	0.04
		DSOFI	0.47	0.20	0.17	2.36	0.001	0.01
Stress	1	DSO	0.73	0.02	0.75	26.87	0.001	0.57
	2	DSO	0.66	0.03	0.67	18.81	0.001	0.39
	2	Threat	0.52	0.15	0.12	3.48	0.001	0.39

*Significant at 0.05 level, ** Significant at 0.01 level.

“××” shows no studies have reported data on that particular outcome measure and treatment.

Tables 3 and 4 demonstrate that the stepwise method of multiple linear regression produced three models to explain the contribution of DSO and PTSD variables to predict depression in the emerging adults’ sample. Out of 10 DSO and PTSD contributor variables, only three variables were found to predict anxiety through the three models. The first model revealed that DSO alone significantly associated with depression, accounting for 68% of the variance in depression scores (R² = 0.68, F (1, 536) = 1171.95, p < .001) with the significant regression coefficient (β = 0.82, t = 34.23, p < .001), indicating the strongest contributor.

Regression analysis produced the second model, which includes NSC with DSO, improved the model significantly (R² = 0.71, F (1, 535) = 44.09, p < .001), and increased the total variance from 68% to 71% to contribute to depression. Both DSO (β = 0.54, p < .001) and negative self-concept (β = 0.32, p < .001) significant contributor for depression.

The third model outcome from multiple linear regression included PTSD in addition to the previous two contributors and further improved the predictive values (R² = 0.71, Adj. R² = 0.71, ∆F (1, 534) = 10.85, p < .001). All three contributors were significant: DSO (β = 0.39, p < .001), negative self-concept (β = 0.35, p < .001), and PTSD (β = 0.14, p < .001), indicating that both DSO and core PTSD are unique contributors to depressive symptoms, with DSO as the highest contributor.

Tables 3 and 4 show that out of 10 DSO and PTSD contributor variables, only three variables were found to contribute to anxiety through the three models. The final model, that is, DSO, PTSD, and DSOFI, explained 50% of variance (R² = 0.50, Adjusted R² = 0.50), F (3, 534) = 181.11, p < .001, in anxiety. The DSO (β = 0.61, p < .001) emerged as the highest contributor of anxiety, followed by PTSD (β = 0.28, p < .001), and DSOFI (β = -0.17, p < .001).

Tables 3 and 4 show that two models, including only two out of 10 variables, DSO and threat appraisal, emerged predicting the stress among emerging adults’ participants, that is, DSO and PTSD criteria, that is, threat appraisal. Both model 58.3% of the variance (R² = 0.58, Adjusted R² = 0.58), F (2, 535) = 374.69, p < .001 in the stress. Again, DSO (β = 0.67, p < .001) appeared as the strongest contributor of stress, followed by the threat appraisal criteria of PTSD (β = 0.12, p < .001).

Regression models showed very large overall effect sizes (Cohen’s f² = 0.92–2.45), indicating substantial explanatory power. At the contributor level, semi-partial correlations (sr²) revealed that DSO accounted for the largest unique variance (sr² up to 0.69), while other contributors (negative self-concept, PTSD, threat appraisal, functional impairment) contributed small-to-medium unique effects.

In summary, across all three emotional distress variables (depression, anxiety, and stress), DSO emerged as the strongest and most consistent contributor, with additional contribution from NSE (DSO criteria), PTSD, DSOFI (DSO criteria), and threat appraisal (PTSD criteria).

Discussion

The present study aimed at assessing the prevalence and severity of emotional distress (through depression, anxiety, and stress) and PTSD and DSO among emerging adults in India, and to explore how PTSD and DSO (ICD-11 diagnosis of C-PTSD) components predict the emotional distress.⁷ This study was conceptualized for a better understanding of trauma-related components and their influence in predicting emotional distress among emerging adults, which seemed to be a gap in the literature and the practice.¹² The current study, which was conducted in a sample of 538 emerging adults, underscores the high burden of emotional distress in this population, which puts forth a need for specific attention.

In the present sample of urban college-going students from Mysore, a high prevalence of DSO (15.2%) and PTSD (20.8%) was observed, indicating considerable trauma-related symptomatology among emerging adults. These prevalence estimates are substantially higher than those reported in the National Mental Health Survey (2015–2016), which found a PTSD prevalence of only 0.2% in the general Indian population. The disparity likely reflects differences in age group, urban college-based sampling, and the reliance on self-report screening tools in the present study. Thus, our findings should be interpreted with caution, as they may partly reflect the unique vulnerabilities of a young, urban, self-selected student sample.

However, the prevalence of both trauma-related variables in Indian populations is comparable to that of Western countries’ studies, which used a similar assessment measure to assess these variables.^24,28 Further, the thematic analysis of the events they reported as traumatic includes fear of the future and career, academic failure, family conflicts, death or loss of loved ones, illness and accidents, childhood maltreatment, sexual boundary violations, social isolations, relationship issues, and chronic illnesses. These trauma themes suggest that the emerging adults often experience cumulative and complex traumatic events and experiences, and denote both individual-specific and socio-contextual forms of trauma, which emphasize the multidimensional nature of trauma as perceived by emerging adults. These findings highlight the importance of considering subjective narrative and contextual realities when assessing trauma and related outcomes. In the Indian context, factors such as academic pressure, family obligations, stigma, and collectivist values may shape how trauma is experienced and expressed, underscoring the need for culturally adapted criteria and interventions.

Emotional distress levels were equally high among the participants, with 53.9% showing symptoms of depression, 66.5% experiencing some level of anxiety, and 36.2% experiencing some level of stress. These results reflect the prior studies quoting emerging adulthood as a vulnerable developmental stage, characterized by identity instability, role confusion, and emotional turmoil.^17,18 Although this prevalence equates with the Western prevalence of emotional distress in this population, they are presenting alarming statistics about the emotional health of emerging adults, underscoring the need for various levels of preventive steps, starting from screening and interventions at the college level, and indicating investment in a policy-driven approach.^29,30

Participants who chose not to disclose sex (although only 1.3% of the sample) and female (66% of the sample) as compared to male (32.7% of the sample) participants appeared significantly higher across all emotional distress parameters, that is, depression, anxiety, and stress, and in trauma-related variables, that is, PTSD and DSO. These findings of this study replicate the gender-based prevalence as reported in Western research.^28,31 These findings highlight further exploration of the factors involved in raising the emotional distress and trauma experiences in female and LGBTQ+ participants.

The current study did not find any significant difference in terms of habitat, whether they were residing in urban, semi-urban, or rural backgrounds, suggesting equal vulnerability of emerging adults to experience emotional distress and traumatic experiences, irrespective of their habitat location in our country. Concerning family background (joint vs. nuclear families), the current study did not find significant differences in levels of anxiety, stress, PTSD, or DSO. However, emerging adults from nuclear families reported significantly higher levels of depression compared to those from joint families. Although existing literature on this topic presents mixed findings, a few studies have reported results consistent with the present study.³²

Further, the individual reporting a current or suspected psychiatric history scored significantly higher across the emotional stress, PTSD, and DSO, suggesting the persistence of trauma symptoms and their comorbidity with depression and anxiety. These findings support the claims about the chronic and overlapping nature of trauma-related psychopathology.³³

The findings of the current research demonstrate high internal consistency for ITQ to measure PTSD and C-PTST (DSO) and DASS-21 to assess depression, anxiety, and stress in the current emerging adult sample, indicating their appropriateness in assessing trauma experiences and psychological distress in Indian populations. These findings align with the international psychometric evaluations of these tools.^23,24 The current research was an attempt to fill the gap in the Indian context using ITQ, which is an international measure to assess the ICD-11 criteria of C-PTSD.^22–24

The DSO showed the strongest and most consistent associations with depression, anxiety, and stress in this emerging adult sample, highlighting the importance of DSO in determining emotional distress. These results are consistent with the very large model effect sizes observed and highlight DSO as the dominant contributor, whereas other trauma-related variables added smaller unique contributions. These findings align with the models suggesting that DSOs are core mechanisms linking complex trauma to emotional distress.^11,34 The DSO includes three constructs, that is, affect dysregulation, negative self-concept, and disturbance in relationships. The findings of this study emphasize that the non-clinical as well as clinical populations should be assessed for these constructs in order not only to address the trauma effects, but also to indirectly screen for the psychiatric comorbidities. Moreover, NSC and PTSD for depression, PTSD and DSOFI for anxiety, and threat appraisal for stress were found as significant contributors, replicating the findings of Western research.³³

Limitations and Future Research

Despite being one of the first studies to examine ICD-11 criteria for C-PTSD and its correlates in the Indian context, this study has several limitations. First, the psychiatric history and clinical conditions were self-reported by participants and could not be clinically verified due to the lack of structured diagnostic interviews. Therefore, prevalence estimates and associations should be interpreted cautiously, and terms such as “probable C-PTSD” may be more appropriate than definitive diagnostic labels. Second, although validated tools were used and psychometric reliability was ascertained in the current sample (which appeared robust for all the measures and domains), the ITQ has not yet undergone full validation in Indian populations. Third, the participants in the sample were included in a single city, which limits the predictability and generalizability to the whole Indian emerging adult population. Fourth, a major portion of the sample comprised female participants, who scored significantly higher on all study variables, which limits the generalizability of the findings across genders. Future research should incorporate clinically verified psychiatric histories and structured diagnostic interviews to assess co-morbid conditions and their interactive effects with C-PTSD. Validation of the ITQ in diverse Indian populations and languages is crucial. Multi-site studies with representative samples from different regions of India are needed to enhance the generalizability of the findings. Future research employing longitudinal designs is recommended to better examine the temporal associations of DSO components.

Implications for Practice

The findings indicate that emerging adults in India experience high emotional distress linked to DSO and PTSD symptoms. The DSO had a consistent predictive role in determining stress, anxiety, and depression, targeting emotional regulation, self-concept, and interpersonal functioning is more warranted. These three components can be made an integral part of all three levels of prevention (primary, secondary, and tertiary), by screening nationwide at the college level and planning and implementing intervention in groups adopting the Layered or Tiered Models of Intervention in educational institutions across the states in the country, as suggested by World Health Organization to achieve sustainable development goal (SGD).^35,36 Given the increasing incidence of student suicides, particularly in premier institutions, universities, and higher education institutions in India, they should integrate trauma-informed practices across all levels of student-environment interaction, including academic settings, campus life, and hostel accommodations. Mental health professionals should consider including trauma-informed assessments in students’ assessment and counseling, and design specific modules for early detection of trauma and management.

Conclusions

The present study brings attention to the significant prevalence of C-PTSD, PTSD, and emotional distress in emerging adults. The study identified that DSO components are key contributors to the experience of depression, anxiety, and stress among these people. Results delineated the multidimensional nature of traumas that the participants experienced and are experiencing, which belong to individual-specific and socio-cultural nature. The findings of the research also support the ICD-11’s distinction between PTSD and C-PTSD and emphasize the need for culturally adapted trauma-informed care models. Furthermore, the current study highlights that addressing DSO-specific symptoms may enhance the treatment outcomes in the sub-clinical emerging adult population.

Supplemental Material

Supplemental material for this article available online.

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

We sincerely thank the JSS Academy of Higher Education & Research, Mysuru, for granting permission to collect data from its two constituent colleges. We are especially grateful to all the student participants whose involvement and cooperation made this research possible.

Author’s Notes

All opinions expressed in this manuscript are solely those of the authors and do not represent the official stance of the Indian Psychiatric Society - South Zonal Branch or the Editorial Board.

Data Sharing Statements

Deidentified individual participant data supporting the findings of this study are available from the corresponding author, upon reasonable request. The proposal should be submitted to manojpandey813@gmail.com.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

We utilized the Grammarly service to enhance the manuscript’s grammar and assume full responsibility for its entire content, including the sections generated by the AI tool.

Ethical Approval

The study was approved (JSSMC/IEC/28082023/ 46 NCT/2023-24) by the institutional review board of JSS Academy of Higher Education & Research, Mysuru, India, in February 2023.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Originality Report (Turnitin)

The manuscript shows a similarity index of 7% as per Turnitin analysis, with quotes, bibliography, and matches of fewer than 14 words excluded, indicating a high degree of originality.

Patient consent

No individually identifiable patient information is included in this manuscript. Written informed consent was obtained from all participants before their involvement in the research survey.

Prior Presentations

No part of this article is presented elsewhere.

Simultaneous Submission

The article being submitted has not been published, simultaneously submitted, or already accepted for publication elsewhere.

Statements and Declarations

To the best of our knowledge, this article does not infringe upon any copyright or property right of any third party.

References

Mahmud

, Hossain

, Muyeed

, . The global prevalence of depression, anxiety, stress, and insomnia and its changes among health professionals during COVID-19 pandemic: A rapid systematic review and meta-analysis. Heliyon, 2021. DOI: 10.1016/j.heliyon.2021.e07393.

Kaur

, Gupta

, Garg

, . Prevalence of depression, anxiety, stress and suicide ideation among undergraduate medical students in India: A systematic review and meta-analysis. Natl J Community Med, 2024; 15(10): 868–883. DOI: 10.55489/njcm.151020244529.

Bailey

, Fairchild

, Hammerton

, . Associations between childhood trauma and adolescent psychiatric disorders in Brazil: A longitudinal, population-based birth cohort study. Lancet Glob Health, 2025; 13(2): 309–318. DOI: 10.1016/S2214-109X(24)00452-2.

Op den Kelder

, Van den Akker

, Ensink

, . Longitudinal associations between trauma exposure and executive functions in children: Findings from a Dutch birth cohort study. Res Child Adolesc Psychopathol, 2021; 50: 295–308. DOI: 10.1007/s10802-021-00847-4.

McLaughlin

, Weissman

and Bitrán

. Childhood adversity and neural development: A systematic review. Annu Rev Dev Psychol, 2019; 1(1): 277–312. DOI: 10.1146/annurev-devpsych-121318-084950.

Hanson

, Chung

, Avants

, . Early stress is associated with alterations in the orbitofrontal cortex: A tensor-based morphometry investigation of brain structure and behavioral risk. J Neurosci, 2010; 30(22): 7466–7472. DOI: 10.1523/JNEUROSCI.0859-10.2010.

World Health Organisation. International classification of diseases (11th revision). https://icd.who.int (2018, accessed 2025).

World Health Organization. International statistical classification of diseases and related health problems: 10th revision. http://www.who.int/classifications/apps/icd/icd (1994, accessed 2025 ).

Ford

and Courtois

. Complex PTSD and borderline personality disorder. Borderline Personal Disord Emot Dysregul, 2021; 8(1): 16. DOI: 10.1186/s40479-021-00155-9.

10.

Hyland

, Vallières

, Cloitre

, . Trauma, PTSD, and complex PTSD in the Republic of Ireland: Prevalence, service use, comorbidity, and risk factors. Soc Psychiatry Psychiatr Epidemiol, 2021; 56: 649–658. DOI: 10.1007/s00127-020-01912-x.

11.

Cloitre

, Hyland

, Bisson

, . ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population-based study. J Trauma Stress, 2019; 32(6): 833–842. DOI: 10.1002/jts.22454.

12.

Chandna

, Suhas

, Patley

, . Exploring the enigma of low prevalence of post-traumatic stress disorder in India. Indian J Psychiatry, 2023; 65(12): 1254–1260. DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_830_23.

13.

Arora

and Satapathy

A systematic review and meta-epidemiological analysis of post-traumatic stress disorder prevalence among adolescents: An update. Indian J Ment Health, 2024; 11(2): 71–83.

14.

Ferrajão

, Frias

and Elklit

Exploring independent and cumulative effects of adverse childhood experiences on PTSD and CPTSD: A study in Indian adolescents. Open J Epidemiol, 2025; 15(1): 142–167. DOI: 10.4236/ojepi.2025.151011.

15.

Schöndorf

, Terhoeven

, Jaehn

, . Characterization of cognitive functioning in complex PTSD compared to non-complex PTSD. Front Psychiatry, 2025; 15: 1433614. DOI: 10.3389/fpsyt.2024.1433614.

16.

Torres

, Utz

and Sack

Predictors of complex PTSD: The role of trauma characteristics, dissociation, and co-morbid psychopathology. Borderline Personal Disord Emot Dysregul, 2023. Epub ahead of print. DOI: 10.1186/s40479-022-00208-7.

17.

Arnett

. Emerging adulthood: A theory of development from the late teens through the twenties. Am Psychol, 2000; 55(5): 469–480. DOI: 10.1037/0003-066X.55.5.469.

18.

Arnett

, Žukauskienė

and Sugimura

The new life stage of emerging adulthood at ages 18–29 years: Implications for mental health. Lancet Psychiatry, 2014; 1(7): 569–576. DOI: 10.1016/S2215-0366(14)00080-7.

19.

Cohen

. Statistical power analysis for the behavioral sciences. 2nd ed. New York: Routledge, 2013, pp.415–424.

20.

Faul

, Erdfelder

, Lang

, . G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods, 2007; 39(2): 175–191. DOI: 10.3758/BF03193146.

21.

Pourhoseingholi

, Vahedi

and Rahimzadeh

Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench, 2013; 6(1): 14–17.

22.

Lovibond

and Lovibond

. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther, 1995; 33(3): 335–343. DOI: 10.1016/0005-7967(94)00075-U.

23.

Sinclair

, Siefert

, Slavin-Mulford

, . Psychometric evaluation and normative data for the depression, anxiety, and stress scales-21 (DASS-21) in a nonclinical sample of US adults. Eval Health Prof, 2012; 35(3): 259–279. DOI: 10.1177/0163278711424282.

24.

Cloitre

, Shevlin

, Brewin

, . The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatr Scand, 2018; 138(6): 536–546. DOI: 10.1111/acps.12956.

25.

IBM Corp. IBM SPSS statistics for windows, Version 20.0 [computer program]. Armonk, NY: IBM Corp, 2011.

26.

Field

. Discovering statistics using IBM SPSS Statistics. 5th ed. London: Sage Publications, 2024, pp.574–585.

27.

Singh

, Junnarkar

and Sharma

. Anxiety, stress, depression, and psychosocial functioning of Indian adolescents. Indian J Psychiatry, 2015; 57: 367–374. DOI: 10.4103/0019-5545.171841.

28.

McGinty

, Fox

, Ben-Ezra

, . Sex and age differences in ICD-11 PTSD and complex PTSD: An analysis of four general population samples. Eur Psychiatry, 2021; 64(1): e66. DOI: 10.1192/j.eurpsy.2021.2239.

29.

Rodríguez-Sáez

, Martín-Antón

, Salgado-Ruiz

, . Emerging adulthood, socioemotional variables and mental health in Spanish university students. BMC Psychol, 2025; 13(1): 1–14. DOI: 10.1186/s40359-025-02804-y.

30.

Brito

and Soares

. Well-being, character strengths, and depression in emerging adults. Front Psychol, 2023; 14: 1238105. DOI: 10.3389/fpsyg.2023.1238105.

31.

Laranjeira

, Querido

, Sousa

, . Assessment and psychometric properties of the 21-item Depression Anxiety Stress Scale (DASS-21) among Portuguese higher education students during the COVID-19 pandemic. Eur J Investig Health Psychol Educ, 2023; 13: 2546–2560. DOI: 10.3390/ejihpe13110177.

32.

Agarwal

and Bahadur

Role of family structure on mental health of adolescents: A comparative study. Int J Indian Psychol, 2023; 11(2): 1571–1578.

33.

Karatzias

, Hyland

, Bradley

, . Risk factors and comorbidity of ICD-11 PTSD and complex PTSD: Findings from a trauma-exposed population-based sample of adults in the United Kingdom. Depress Anxiety, 2019; 36(9): 887–894. DOI: 10.1002/da.22934.

34.

Brewin

. Complex post-traumatic stress disorder: A new diagnosis in ICD-11. BJPsych Adv 2019; 26(3): 145–152. DOI: 10.1192/bja.2019.48.

35.

World Health Organization. Comprehensive mental health action plan 2013–2030. https://www.who.int/publications/i/item/9789240031029 (2021, accessed 2025 ).

36.

Department of Economic and Social Affairs, United Nations. The 17 goals. https://sdgs.un.org/goals (2015, accessed 2025 ).

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